Inguinal Hernia Surgery – Tailored Approach
The guideline of the HerniaSurge group, a coalition of all international hernia societies, reflects the current scientific status in inguinal hernia surgery [1]. It allows for the differentiated use of the recommended surgical techniques depending on the clinical conditions presented by the patient [2, 3, 4]. This differentiated approach is referred to as a "tailored approach."
Indication for Surgery in Men
In men with asymptomatic or minimally symptomatic inguinal hernias, the concept of "watchful waiting" is considered, as the risk of incarceration is low. The number of men who develop symptoms or pain over time is relatively high, so they should then be referred for surgery. In men with symptomatic inguinal hernias, the concept of "watchful waiting" does not apply, as the risk of incarceration cannot be assessed due to a lack of studies.
Indications for Surgery in Women
Femoral hernias occur more frequently in women than in men. Since no diagnostic method can reliably distinguish between inguinal and femoral hernias, and femoral hernias incarcerate more frequently than inguinal hernias, the indication for surgical repair of hernias in women should be made promptly.
Repair of a Primary Unilateral Inguinal Hernia in Men
Mesh-based techniques are recommended for surgical repair. Whether non-mesh techniques are a safe alternative for young men with small lateral inguinal hernias cannot be assessed due to a lack of studies.
Repair of a Primary Unilateral Inguinal Hernia in Women
In anterior mesh procedures (e.g., Lichtenstein) and non-mesh procedures, a femoral recurrence is found in about 40% of recurrence surgeries. A possible explanation is that in anterior procedures, the transversalis fascia is not opened (exception: Shouldice), and thus no exploration of the preperitoneal space occurs. Therefore, the guidelines recommend posterior procedures with exploration of the femoral defect, namely the laparoscopic mesh procedures TEP and TAPP, for women.
Repair of a Primary Unilateral Inguinal Hernia in Men with an Open Anterior Mesh Procedure (Lichtenstein, PHS, Plug and Patch)
The current guideline recommends the Lichtenstein procedure for open anterior repair. PHS and Plug and Patch procedures are no longer recommended despite equivalent results, as an excessive amount of foreign material is introduced, and the mesh products are more expensive compared to the simple flat mesh. The introduction of mesh material into both the anterior and posterior layers of the groin, which complicates the repair of recurrent hernias, also argues against PHS and Plug and Patch.
Repair of a Primary Unilateral Inguinal Hernia in Men with an Open Preperitoneal Procedure (TIPP, TREPP, Onstep, Ugahary) versus Lichtenstein Technique
The data comparing open preperitoneal procedures versus the Lichtenstein technique is sparse. Therefore, open preperitoneal procedures cannot be recommended for the repair of primary inguinal hernias in men at this time. Additionally, the mesh materials are more expensive than the simple flat mesh for the Lichtenstein repair.
Repair of a Primary Unilateral Inguinal Hernia in Men with Lichtenstein Technique versus Laparoscopic Techniques
If the surgeon has the appropriate expertise and the technical equipment is available, the guideline recommends a laparoscopic technique for the repair of primary male inguinal hernias. Laparoscopic techniques and the Lichtenstein procedure have comparable recurrence and complication rates. Minimally invasive procedures have the advantage of faster recovery due to lower postoperative discomfort. Chronic pain also occurs less frequently with MIC procedures. However, laparoscopic procedures have a longer learning curve compared to the Lichtenstein technique. Rare but serious complications can occur, especially at the beginning of the training phase.
Repair of a Primary Unilateral Inguinal Hernia in Men: TEP versus TAPP
TEP and TAPP have comparable operation times, complication rates, chronic pain rates, and recurrence rates. With appropriate expertise, serious complications are very rare, with TAPP having more organ injuries and TEP having more vascular injuries and conversions to open procedures. The learning curve for TEP is longer than for TAPP. Ultimately, the choice of procedure - TEP or TAPP - depends on the surgeon's training, skills, and experience.
Repair of a Primary Bilateral Inguinal Hernia in Women and Men
Based on numerous studies [5, 6, 7, 8], the guideline recommends laparoscopic procedures for the repair of bilateral inguinal hernias in both men and women.
Repair of a Recurrent Hernia in Women and Men
It is recommended to repair recurrences after previous anterior suture and mesh procedures with a laparoscopic technique operating in the previously unaffected anatomical layer. Conversely, recurrences after minimally invasive preoperative procedures should be repaired with an anterior procedure using the Lichtenstein technique.
Repair of an Incarcerated Inguinal Hernia in Women and Men
Different recommendations are made for the treatment of incarcerated inguinal hernias. Due to a lack of evidence for an optimal approach, the HerniaSurge group advocates a "tailored approach." The International Endohernia Society, on the other hand, recommends an initial exploratory laparoscopy [9, 10], so that the contents of the hernia sac can be repositioned, possibly after a cranial incision of the hernia ring. In 90% of cases, the bowel recovers, and in the remaining 10%, bowel resection is indicated. If no bowel resection is required, a TEP or TAPP can be performed in a clean surgical area. If bowel resection is required and the surgical area is contaminated, simultaneous repair of the hernia using the Lichtenstein technique can be performed, or it can be repaired in a staged or later procedure.
Antibiotic Prophylaxis in Inguinal Hernia Surgery
The HerniaSurge group recommends no antibiotic prophylaxis for laparoscopic techniques in inguinal hernia repair. However, prophylaxis should be performed for every patient with open repair and a mesh.
Meshes in Inguinal Hernia Surgery
According to the recommendations of the HerniaSurge group, only flat meshes are used for mesh-based inguinal hernia repair (Lichtenstein, TEP, TAPP). Heavy and lightweight as well as small and large pore meshes are available.
The influence of mesh weights on the outcome of inguinal hernia surgery is not clearly determinable, which already fails due to the lack of a clear definition of lightweight and heavyweight meshes. Meta-analyses and RCTs could not clearly demonstrate that repair with lightweight meshes leads to a better postoperative outcome. However, the use of lightweight meshes does not increase the recurrence rate.
From the perspective of introducing as little foreign material as possible, lightweight meshes (which are usually also large-pored) can be used for inguinal hernia repair from the perspective of the HerniaSurge group.
Mesh Fixation in Inguinal Hernia Surgery
In the literature, there is no difference in recurrence and wound infection rates for the various mesh fixation techniques - suture, glue, self-fixation - in open anterior mesh repair. Mesh fixation with glue (fibrin or cyanoacrylate) may reduce perioperative and chronic pain. Therefore, despite the low level of evidence, the HerniaSurge group recommends atraumatic mesh fixation in the open mesh-based technique. In TEP, mesh fixation is almost always unnecessary. Large medial hernias are problematic, which is why fixation is recommended in these cases for TEP and TAPP, possibly also with staples.